S9 Ep27: The right to choose to die

Episode Summary

Executive Summary: The episode explores assisted dying through economist Alvin Roth’s concept of “repugnant transactions”: activities some people want but others want banned for moral reasons. Roth argues policy should rely on evidence, not absolutes, because bans can create black markets or covert practices and may increase suffering. The conversation compares U.S., Canadian, and other regimes, emphasizing safeguards, consent, and risks to vulnerable people.

Main Topics: Assisted dying as a repugnant transaction (Priority: 5/5): Roth defines medical aid in dying as a contested exchange that some want to access while others oppose on moral or religious grounds. He stresses the term is technical, not a moral verdict. U.S. vs. Canadian legal frameworks (Priority: 5/5): The discussion contrasts U.S. laws, which generally restrict MAID to terminal diagnoses, with Canada’s broader standard allowing patients with grave, irremediable conditions even if death is not imminent. Evidence, black markets, and policy trade-offs (Priority: 5/5): Roth argues that bans do not eliminate contested practices; instead they may drive them underground. He uses this to justify evaluating outcomes rather than relying solely on moral objections. Safeguards, consent, and mental health (Priority: 4/5): The episode examines waiting periods, multiple physicians, self-administration rules, and exclusion of acute suicidal ideation or dementia in many jurisdictions to reduce coercion and impulsive decisions. Vulnerability and pressure on patients (Priority: 4/5): A major concern is whether elderly, disabled, or dependent patients feel pressured to die. Roth notes some evidence suggests no population-level overuse by vulnerable groups, though individual coercion remains possible. Choice architecture and physician training (Priority: 3/5): The conversation highlights that when and how MAID is offered matters; inappropriate offers in emergency settings illustrate the need for careful clinical protocols and better training. Broader moral economics agenda (Priority: 3/5): The episode situates assisted dying alongside other controversial markets Roth studies, such as abortion, IVF, contraception, plasma donation, and kidney donation, showing the same framework across policy debates.

Key Arguments: Moral objections alone do not settle policy; contested practices still exist, so society must consider the least harmful practical regime. Legal bans often fail to eliminate repugnant transactions and may shift them into black markets or covert channels. Evidence from jurisdictions that allow MAID is gradually accumulating and can inform better regulation. U.S. MAID laws are typically limited to terminal illness, while Canada’s rules are broader and more focused on relief from irremediable suffering. Safeguards such as waiting periods, multiple medical opinions, and self-administration are designed to distinguish MAID from homicide and reduce impulsive decisions. Medical aid in dying should not be conflated with acute suicidality; mental health crises require treatment and evaluation rather than assisted death. Concerns about pressure on vulnerable patients are real, but cited population-level evidence does not show disproportionate access by vulnerable groups. Choice architecture matters: MAID should be offered in appropriate contexts, not casually in emergency rooms or as a default option. Even when people oppose heroin or assisted dying morally, prohibition can produce worse real-world outcomes than regulated access. Costs matter both to individuals and to society, including suffering, loss of autonomy, and potentially unnecessary end-of-life medical spending.

Data Points: U.S. MAID jurisdictions: 12 or 13 - Al Roth says states plus the District of Columbia that allow medical aid in dying number around 12 or 13. Typical terminal prognosis window: within 6 months - Many U.S. MAID laws require a reasonably certain death within about six months. Publication date of Moral Economics: 21 May 2026 - The episode’s outro identifies the book’s publication date. Heroin overdose deaths: 100,000 a year - Roth cites U.S. overdose deaths to illustrate that prohibition does not eliminate contested markets. Hippocratic Oath origin: 5th century BCE - Used to show that physician objections to helping patients die are historically longstanding. Committee debate length in UK bill: 35+ hours - A guest quote mentions seven days of committee at about five hours per day before Section 1 was reached.

Pivotal Quotes: "We can't avoid thinking about trade-offs, and we require evidence to think about them clearly, and we should not hesitate to look at evidence and gather it where we can." — Alvin Roth: Closing summary of the book’s policy approach and the episode’s central thesis. "A repugnant transaction is a transaction that some people would like to engage in, and other people think they shouldn't be allowed to, for moral or religious reasons." — Alvin Roth: Roth defines his key analytical term early in the interview. "When you put legal bans in place for a repugnant transaction... you often get black markets." — Alvin Roth: Roth explains why prohibition may not solve morally contested behaviors.

Implications: Listeners are urged to view assisted dying as a policy design problem: focus on evidence, safeguards, and unintended consequences. For lawmakers and clinicians, the episode suggests that tightly regulated access may reduce suffering better than outright bans.